Provider Demographics
NPI:1578632865
Name:RAGUSA, MARIO A (MD)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:A
Last Name:RAGUSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:105 NEWBRIDGE RD
Mailing Address - Street 2:1
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801
Mailing Address - Country:US
Mailing Address - Phone:516-931-4312
Mailing Address - Fax:516-931-0588
Practice Address - Street 1:105 NEWBRIDGE RD
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801
Practice Address - Country:US
Practice Address - Phone:516-931-4312
Practice Address - Fax:516-931-0588
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2010-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081638207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B02084Medicare UPIN
124721Medicare ID - Type Unspecified